Fill and Sign the First Report of Injury New Mexico Mutual Form

N EW MEXICO WORKERS' COMPENSATION ADMINISTRATION E MPLOYERS' FIRST REPORT OF INJURY OR ILLNESS 2410 CENTRE AVE. SE ♦ PO BOX 27198 ALBUQUERQUE, NM 87125-7198 OFFICIAL USE ONLY PLEASE PRINT IN BLACK INK OR TYPE. CARRIER / ADMINISTRATOR CLAIM # OSHA LO G NUMBER REPORT PURPOSE CODE JURISDIC TION JURISDIC TION CLAIM NUMBER INSURED REPORT NUMBER MPLOYER ( NAME & ADDRESS INCL ZIP ) E LOCATION # G E N E R A L PHONE NUMBER EMPLOYER FEIN EMPLOYER'S LOCATION ADDRESS ( IF DIFFERENT ) INDUSTRY CODE POLICY PERIOD TO CHECK IF APPROPRIATE CARRIER ( NAME, ADDRESS & PHONE NO ) SELF INSURANCE CLAIMS ADMINISTRATOR ( NAME, ADDRESS & PHONE NO ) FEIN CARRIER POLICY / SELF-INSURED NUMBER ADMINISTRATOR FEIN C A R R I E R C L A I M S A D M I N AGENT NA ME & CODE NUMBER NAME ( LAST, FIRST, MIDDLE ) DATE OF BIRTH SOCIAL SECURITY NUMBER DATE HIRED STATE OF HIRE GENDER MARI AL STATUS T MALE UNMARRIED INGLE/DIVORCED S OCCUPATION/JOB TITLE OR (SOC) CODE FEMALE MARRIED ADDRESS ( INCL ZIP ) UNKNOWN SEPARATED EMPLOYMENT STATUS E M P L O Y E E PHONE NUMBER # OF DEP ENDENTS UNKNOWN NCCI CLA SS CODE DAY MONTH FULL PAY FOR DAY OF INJURY? YES NO W A G E PER: RATE WEEK OTHER: # DAYS WORKED/WEEK DID SALARY CONTINUE? YES NO TIME EMPLOYEE BEGAN WORK AM AM PM DATE OF INJURY/ILLNESS TIME OF OCCURRENC E PM LAST WORK DATE DATE EMPLOYER NOTIFIED DATE DISABILITY BEGAN CONTACT NAME / PHONE NUMBER TYPE OF INJURY/ILLNESS PART OF BODY AFFECTED DID INJURY /ILLNESS EXPOSURE OCCUR ON EMPLOY R'S PR MISES? E E Y ES NO TYPE OF INJURY / ILLNESS CODE PART OF BODY AFFECTED CODE DEPARTMENT OR LOCATION WHERE ACCIDENT OR ILLNESS EXPOSURE OCCURRED ALL EQUIPMENT, MATERIALS, OR CHEMICALS EMPLOYEE WAS USING WHEN ACCIDENT OR ILLNESS EXPOSURE OCCURRED SPECIFIC ACTIVITY THE EMPLOYEE WAS ENGAGED IN WHEN THE ACCIDENT OR ILLNESS EXPOSURE OCCURRED WORK PROCESS THE EMPLOYEE WAS ENGAGED IN WHEN ACCIDENT OR ILLNESS EXPOSURE OCCURRED HOW INJURY OR ILLNESS / ABNORMA L HEALTH CONDITION OCCURRED. DESCRIBE THE SEQ UENCE OF EVENTS AND INCLUDE ANY OBJECTS OR SUBSTANCES THAT IRECTLY INJURED THE EMPLOYEE OR MADE THE EMPLOYEE ILL. D CAUSE OF INJURY CODE DATE RETURNED TO WORK IF FATAL, GIVE DATE OF DEATH WERE SAFEGUARDS OR SAFETY EQUIPMENT PROVIDED? YES NO O C C U R R E N C E WERE THEY USED? YES NO IAL TREATMENT INIT NO MEDICAL TREATMENT MINOR: BY EMPLOYER MINOR CLINIC/HOSPITAL T R E A T M E N T N / HEALTH CARE PROVIDER ( NAME & ADDRESS ) PHYSICIA NAME & ADDRESS ) HOSPITAL ( EMERGENCY CARE HOSPITALIZED > 24 HRS WITNESSES ( NAME & PHONE # ) FUTURE MAJOR MEDICAL/ LOST TIME ANTICIPATED DATE ADMINISTRATOR NOTIFIED O T H E R DATE PREPARED PREPARER'S NAME & TITLE NM WCA FORM E1.2 EQUIVAL\ ENT TO OSHA'S FORM 301 FORM IA-1 (7/02) © IAIABC 2002 Completion of this form is not an admission that the claim is comp ensable under the Workers’ Compensation Act. NEW MEXICO WORKERS' COMPENSATION ADMINISTRATION Phone: (505) 841-6000 In-State Toll Free: 1-800-255-7965 FARMINGTON: 505-599-9746/1-800-568-7310 LAS CRUCES: 505-524-6246/1-800-870-6826 LAS VEGAS: 505-454-9251/1-800-281-7889 LOVINGTON: 505-396-3437/1-800-934-2450 Roswell: 50 5-623-3781 Santa Fe: 505-476-7381 FILING INSTRUCTIONS PURPOSE: To report all alleged work-related injuries or illnesses resulti ng in more than 7 days of lost work or in death of the worker. This form is not an admission or denial by the employer as to whether the worker's alleged inju ry or illness is compensable, and must be ompleted by the employer or the employer's representative. c WHEN TO FILE: This form must be filed within 10 days of knowledge of any a lleged work-related injury or illness that results in more than days of lost work. It must be filed even if the employer disputes th e worker's claim of work-related injury or illness. 7 WHERE TO FILE: Mail the original form to the New Mexico Workers' Compens ation Administration (Attention: Statistics) at the address on he front of this form. Copies must also be provided to the worker and the employer's workers' compensation insurer. t PENALTIES: Each instance of failure to file this form when required is punishable by a fine of up to $1,000.00. INSTRUCTIONS FOR COMPLETION FILLING IN THE SHADED AREAS IS OPTIONAL. The employer may wish, however, to use some of these areas (such as "Witnesses") for the employer's records. Expanded in structions are found in the publication Guide to Completing the Employer's First Report of njury or Illness , available from the Administration's Albuquerque office (ca ll either number bold-faced above and ask for Statistics). I Please print in black ink or type, and ensure that all entries are legible before submission. An illegible or incomplete E1 ma y be returned. NAIC CODE: Represents the nature of the employer's business at the location where the wo rker was employed at the time of injury or illness exposure; derived from the federal governm ent publication North American Industry Classification System Manual . Include this code known. if E MPLOYER'S LOCATION ADDRESS: Facility where the worker was employed at the ti me of injury, if different from mailing address. CARRIER: Name, mailing address and telephone number of the licensed busi ness entity issuing a contract of insurance and assuming nancial responsibility on behalf of the empl oyer. A WCA-approved self-insured employ er should enter its business name. fi CLAIMS ADMINISTRATOR: Name, mailing address and telephone number of the insur ance carrier, agency, third party administrator or elf-insured responsible for adjusting the claim. s E MPLOYER, CARRIER OR ADMINISTRATOR FEIN: Federal Identification Number, assi gned by the Internal Revenue Service. D ID SALARY CONTINUE? Shows if the employer is continui ng to pay the worker's regular wages without charge to employee benefits. DATE OF INJURY/ILLNESS: In the case of an occupational illness (arising from the worker's activity or exposure over an extended eriod), enter the date of di agnosis or the date first reported to the employer as possibly work-related. p DATE EMPLOYER NOTIFIED: The date the worker first notified (ver bally or in writing) the employer or the employer's representative of the lleged work-related injury or illness. a D ATE DISABILITY BEGAN: The first full day on which the worker lost time from work due to the injury or illness. TYPE OF INJURY OR ILLNESS: Briefly describe the nature of the injury (such as lacerations to the forearm) or illness (such as carpal unnel syndrome). Be as specific as possible. t P ART OF BODY AFFECTED: The specific part of body affected by the injury or illness (for example, right forearm, lower back). DEPARTMENT OR LOCATION: If the accident or illness exposure did not occur on the employer's premises, ent er specific address or cation (for example, Client's office at 123 Main St., Yourtown, NM 87xxx). For occurrences in New Mexico, give ZIP or COUNTY . lo ALL EQUIPMENT, MATERIAL OR CHEMICALS: List all equipment, materials and/or chemicals the worker was using, applying, handling or operating when the injury or illness exposur e occurred. Be specific (for example, decorator's scaffolding, electric sander, paintbrush and aint). Enter "NA" if not applicable. NO TE: The items listed do not have to be direct ly involved in the worker's injury or illness. p SPECIFIC ACTIVITY: Describe the specific activity t he worker was engaged in when the accident or illness exposure occurred (for xample, sanding ceiling woodwork in preparation for painting). e WORK PROCESS: Describe the work process the worker was engaged in w hen the accident or exposure occurred, such as building aintenance. Enter "NA" for not applicable if not engaged in a work process (for example, if the worker was walking along a ha llway). m HOW INJURY OR ILLNESS OCCURRED: Describe how the injury or illness/abnormal health condition occurred. Be very specific. Include the sequence of events and name any objects or substances that directly injured the worker or made the worker ill. (For example: orker stepped back to inspect work and slipped on some scrap metal. As worker fell, worker brushed against the hot metal.) w WORKER'S/EMPLOYER'S RIGHTS AND RESPONSIBILITIES If you, the worker, believe that benefits are due you under the Workers' Compensation Act, and your employer or the employer's insurance carrier has failed or refused to make tho se benefits available to you, you have a right to file a complaint with the New Mexico Workers' Compensation Administration. Workers and employers with questions about rights or responsibilities under the Act may c ontact an ombudsman at any Workers' Compensation Administration regional office for information and assistance. To do so\ , call any of the above-listed telephone numbers (8 a.m. to 5 p.m. M-F).